Instructions for Completing the MassHealth Prescription and Medical Necessity Review Form for
Ambulatory Infusion Pumps (Insulin Pumps)
Sections 1, 2, 3, 4, 5, and 6 must be completed by the provider of DME. Sections 4A, 5A, and 7 must be completed by the prescribing provider
or his/her employee. Section 8 must be completed by the prescribing provider.
Instructions for the
Use of this Form
Providers of DME should use this form when obtaining a Prescription and Letter of Medical Necessity from the member’s
prescribing provider for Ambulatory Infusion Pumps (Insulin Pumps), and as an attachment to a prior authorization
(PA) request for insulin pumps. Providers of DME are responsible for ensuring compliance with applicable MassHealth
regulations and guidelines when using this form. MassHealth reserves the right not to accept the form if it is completed
improperly, or if the provider has failed to meet applicable MassHealth regulations, requirements, and guidelines,
including without limitation medical necessity requirements. Please refer to the
MassHealth
Guidelines for Medical
Necessity Determination for Ambulatory Infusion Pumps (Insulin Pumps)
for further information about required
clinical documentation and information that must be submitted for PA requests for ambulatory infusion pumps (insulin
pumps). A copy of this completed form (including all attachments and supporting documentation) must be maintained in
the member’s medical record at the prescribing provider’s oce and at the provider of DME’s oce.
Section 1 Enter the date of delivery of ambulatory infusion pumps (insulin pumps) at the top of the form. The date of delivery
on this form must match the date on the delivery slip. Enter the member’s name, MassHealth member ID, address
(including apartment number if applicable) telephone, date of birth, gender, height, weight, and applicable ICD
diagnosis code(s) with their descriptions.
Section 2 Enter the prescribing provider’s name, NPI, address, telephone, and fax number.
Section 3 Enter name of provider of DME, NPI, address, telephone, and fax number.
Section 4 Enter the description of the ambulatory infusion pump(s) (insulin pump(s)) being requested, the correct HCPCS
code(s), and the modifier(s). Please do not list pump supplies in Section 4, but separately complete Section 5 for that
purpose. Please be sure to use the correct modifier for the length of time you are requesting.
Section 5 Enter the description of the pump supplies being requested, if any, for use with the ambulatory infusion pumps
(insulin pumps), along with the correct HCPCS code(s) and modifiers.
Section 6 The provider of DME must sign and enter the date the form was completed. By signing the form, the provider is
making the certifications contained above the signature line. Note: Signature and date stamps, or the signature of
anyone other than the provider of DME or a person legally authorized to sign on behalf of a legal entity (if the
provider of DME is a legal entity), are not acceptable.
Sections 4A, 5A, and 7 must be completed by the prescribing provider or his/her employee.
Section 4A The prescribing provider(or his/her employee) must enter the total number of months that the prescribing provider
expects the member will require use of the ambulatory infusion pump (insulin pump). The total number of months
cannot exceed 13 months from the date of the original prescription.
Section 5A The prescribing provider or his/her employee must enter the total monthly quantity of pump supplies and the number
of refills. The total number of months cannot exceed 13 months from the date of the original prescription.
Section 7 The member’s prescribing provider or his/her sta must complete the medical justification for the requested
product(s). This section must be filled in, and applicable supporting documentation must be attached.
Section 8 must be completed by the prescribing provider.
Section 8 The member’s prescribing provider listed in Section 2 of this form must review all information completed on and
attached to this form, and must sign and date the form. By signing the form, the prescribing provider is making the
certifications contained above the signature line. The form must be signed by the member’s prescribing provider,
who must be either the member’s physician (MD), nurse practitioner (NP), or physician assistant (PA). The
prescribing provider must check the applicable credential(s).
If you have any questions about how to complete this form, please contact the MassHealth Customer Service Center at 1-800-841-2900.
